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.. ' - � FEg 21, ����. , - +
. _ NOTTCE OF CLAIM FOKM to the City. of Saint Paul, Mi��t�LERK
Minnesota State Stattfte 466.03 statts that"...evcry penorc...who claims damagu froM any municipality...shall cause to 6e presented to thc
- governing body of the municipaliry within 180 days after tht alleged loss or injury is discovered a notice stating the time,pluce,and
� circwnstances thereof,and the arnount of comperrsation or other relief denwnded"
Please complete this form in its entirety by clearly typing�r printing your answer to each queshon. If more space is
needed,attach additional sheets. Please note that you may or may not be contacted by telephone to discuss your claim
cinumstances,so provide as much information as necessary to explain your claim,and the amount of compensation being
requested. This form must be signed,and both pages completed. If something does.not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO:
CITY CLERK, 15 WEST KELLOGG BLVD, 290 CTTY HALL,SAINT PAUL,MN 55102
First Name l� ��� Middle Initial �J Last Name ��ND
Company or Business Name, if applicable
Street Address_._33� C��D�.� �--� .._ �d � _____ ___�
� �/�
Ciry L CTTC.� ���al,� �� State _ �" �� Zip Code
Daytime Telephone �o( �Z ) �s� 4�`�' Evening Telephone (_) �
{ r
Date of Accident/Injury or Date Discovered � �' Time am/pm (circle)
Please state, in detail, what occurred, and why you are submitting a claim. Please indicate why or how you
feel the City of Saint Paul or it employees are involved andLor responsible. :
6
S , �.—,r'.i, �:�V`�\ ' ;+� � 1 r t l,,.l,�,\t'�... �,� ,. , �,..,�
' E_ t:.� `; - i e', � t,'\'. _..�, ���, •t `�# G'��
r r��`� E, �.. a 't .t�_ . � � �, " X -
,v r ;�.��� �> . � � 4 � #._ �� s. :� � � - �
� ��, ! . . . ..�� � .Y,p� _1�— � •'e\ �� �,�.,i'„� i � ��` '
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P ! 6� �eti� tL; t
t 1 , `�� i � —
� � � .t� ��� t 1-�
� � i ','v` .a '��.�� _-�
Please check the box(es) that most closely represenc the reason for completing this form:
❑ Vehicle was damaged in an accident ❑ Vehicle was damaged during a tow
❑ Vehicle was damaged by a pothole or condition of the street l9 Vehicle was damaged by a plow
❑ Vehicle was wronafully towed and/or ticketed ❑ Injured on Cit��rope�tX =
❑ Other rype of property damage—please specify
❑ Other type of injury—please specify
❑ Other type not listed—please specify �
In order to process your claim You need to include copies of all applicable documents. This is a general
guideline of what should be submitted with a claim form, but it is not all inclusive. You may be asked to
provide additional information depending on your claim.
O Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle, or the
actual bills and/or receipts for the repairs
O Towing claims: leaible copies of any tickets issued and copies of the impound lot receipts
O Other property dama;e: repair estimates, detailed list of dama�ed items
O Injury claims: medical bills, receipt� � :(� t•��! 0� 93.� h18t �
O Photo�raphs can be provided but will"not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
. . . . � � . . . z`SA .x..:T',:ia.:;
. _ �' . . . � . ' . . . . .. _ _ ...'. . . - . . . . . ' .. , _. : . . . ., t s�,r- F..
Notice of Claim Form, City of Saint Paul,page two -
All Claims—please complete this section
Were there witnesses to the incident? Yes No : Unlrnown (circle)
If yes,please provide their names, addresses and telephone numbers:
Were the police or law enforcement called? es No - Unknown (circle)
If yes, what department or agency? `S l��1`� Case or report# `3 - 2�125 I 3
Where did the accident or injury take place? Provide street address, cross street, intersection, name of park
or facility, closest landmark, etc. Please be as detailed as possible. If helpful, attach a diao am.
"�" ('`;r�T�t`)) ��� '��►� {� ��.��t��.S� i�-v ��'I
r� ,< <
Please indicate the amount you are seeking in compensation from this claim or what you would like the City
to do to resolve this ciaim to your satisfaction.
Vehicle Claims—please complete this section ❑ check box if this section d_oes not applv
Your Vehicle� Year���'���= Make �GJIr'� Model LE��N y�
License Plate Number State �'� Color T-���`�
Registered Owner
Driver of Vehicle G a�� �1 s.,/�
Area Damaaed �I��N'f- ��.ti7
Ciry Vehicle: Year ��� � Make �- ' ' '��? Model
License Plate Number 3 S[ate Color ��-v�c
Driver of Vehicle (City Employee's Name) ���1J J�l� i�.3��
Area Damaged
Iniurv Claims—please complete this section D check box if this section does not applv
How were you injured? h i.L l�� (�'.^/ U!J �� M�l�-('T
What part(s) of your body were injured? �f,l� �l�Si� S—fU�'���[,1�1�
_____--.---
Have you souaht medical treatment? Yes No CPlan.__ n�in�to Seek Treatme (circle)
When did you receive treatment? (provide date(s))
r�ame cf Medical P:cvider(s;:
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you miss work? (provide date(s))
Name of your Employer:
� Address Telephone
� Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this form,you are stating that a1l informatiort you have provided is true and correct to the best of your knowfedge. Unsigned
jorms may not be processed SubmilTing a false claim can result in prosecution. �
Print the Name of the Person who Completed Form:
�
Signature of Person 1Vlaking the Clai :
Date form was completed �.� �� Revised April 2006
\
.�
�
. �
name is: �
My i �rst) (r'I•n ast)
I work for the Department of Public Works in the J D�vision) �� •
My City vehicle information:
� E L � � ( `n�
��3 � odel
�U b�� (License#)�� alce) � �
M �
/ (Type of vehicle) . •
If you wish to make a claim against the Cite�as�o Peuof Cla me forlm.en
� Service Off'ice" at(651)266-8989 and requ
You may also obtain this form at the City's web site. The web site is
httn•//www ci stpaul.mn.us\depts\cso
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